Facility Assessment Lacks Required Stakeholder Involvement and Staffing Contingency Plan
Penalty
Summary
The facility failed to ensure that its Facility Assessment included the active involvement of required individuals, such as direct care staff, direct care representatives, residents, residents' representatives, and family members, in its development. Review of the Facility Assessment dated 3/12/25 showed no evidence of participation from these groups. This omission was confirmed during an interview and document review with the Administrator, who acknowledged the lack of involvement from these stakeholders and was aware of the updated CMS guidance requiring such participation. Additionally, the Facility Assessment did not include a contingency plan for staffing needs, as required by the revised CMS guidance. The Administrator verified that the assessment lacked this component and had not been updated to reflect the latest requirements. The absence of both stakeholder involvement and a staffing contingency plan was identified through document review and staff interview, indicating noncompliance with current regulatory expectations.